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Physicians deliver street medicine.

Dr. Jim Withers is a familiar sight on the nighttime streets of Pittsburgh.

That's because for the last 15 years he's been leaving the hospital behind to seek out unsheltered homeless people in need of medical attention. When he started in 1992, dressed down and carrying a small backpack of medical supplies, he had to work hard to earn the trust of the homeless individuals he met. Today he's well known among his patients, and the reputation of his program--Operation Safety Net--has grown across the country and around the world.

In October, Dr. Withers will be among a group of physicians and nurses from the United States, Europe, and Asia who will gather in Houston for the third annual International Street Medicine Symposium. Sponsored by GlaxoSmithKline and the Robert Wood Johnson Foundation, the meeting will bring together health care providers who care for the hard-to-reach group known as the unsheltered homeless. The meeting is a chance for street medicine providers to compare notes and swap ideas about fund-raising, outreach, and malpractice coverage.

The field is "growing very rapidly," said Dr. Withers, who, in addition to his role as director of Operation Safety Net, teaches internal medicine at Mercy Hospital in Pittsburgh.

Operation Safety Net has been the inspiration for programs in other cities. When it began in 1992, Dr. Withers was its sole physician. Seeking to reach out to the homeless population not housed in shelters, he teamed up with a formerly homeless man who made frequent trips back to the street to distribute sleeping bags and sandwiches. With this entree into the community, Dr. Withers began to offer his medical services. "I really had this vision of going and getting out under the bridges," he said.

Months went by before he finally confessed his nighttime efforts to the CEO of his hospital. To his surprise, she embraced the idea immediately and sought to find ways that the hospital could aid his project. With that official backing, Dr. Withers quickly expanded his efforts with more volunteers and even a program administrator to keep things running at the office.

Out on the street, many medical needs can be met immediately, he said. For example, Dr. Withers and his team often treat wounds and burns, provide antibiotics, perform general skin care, and offer other primary care services. "There's a huge amount of hypertension on the streets," he said.

But although there's a lot he can do for his homeless patients on the spot, the idea is not to be their only source of care. Dr. Withers said.

The goal is always to move people into more traditional health care settings, agreed Dr. Noemi "Mimi" Doohan, codirector of Doctors Without Walls in Santa Barbara, Calif. "We're always sticking to the principle that every person should have a personal medical home," she said.

Dr. Doohan, a family physician who cofounded the Santa Barbara program with internist Dennis Baker, modeled her program on the work being done by Dr. Withers in Pittsburgh.

Doctors Without Walls began in 2005 and includes not only street medicine, but also care to the homeless in shelters, in the hospital, and at respite sites. So far, Dr. Doohan and her team of volunteers have focused on the Isla Vista neighborhood, considered something of a student ghetto with a stable, unsheltered, chronic homeless population.

The neighborhood already has an excellent not-for-profit clinic, so Dr. Doohan and her team don't try to duplicate those services. Instead, they go into the streets to identify homeless people in need of medical care and to walk them into the clinic where they can receive that care; if needed, they arrange for transfer to higher levels of care. This year, they plan to expand the program into areas farther from the clinic and to provide care on the street.

One of the keys to their success has been working with the existing programs and agencies that provide services to the homeless, she said. Dr. Doohan and her team can provide more mobile and flexible care, but they try to ensure that their services build on what is already available. "We're trying to fill in the gaps," she said.

Since 2005, the program has survived on a shoestring budget and the work of its completely voluntary staff.

But one of the challenges the program has faced is a sense among local physicians that there aren't medical volunteer opportunities in their own hometown. Dr. Doohan is trying to get the message out that working with the homeless can be as rewarding as going to a distant disaster area. "We look at homelessness as a chronic disaster."

For those involved, the time can be very rewarding. "It's very inspiring work," Dr. Doohan said. "It reminds us of why we got into medicine in the first place."

Once volunteers get involved in street medicine, they are usually hooked, said Dr. David M. Deci, a family physician at West Virginia University, Morgantown, and faculty adviser for MUSHROOM (Multidisciplinary Unsheltered Homeless Relief Outreach of Morgantown).

"In part, it really validates us as physicians," he said. "You do what you can. You're not constrained by time."

MUSHROOM, a student-run initiative, began in 2005. The medical students had heard about Dr. Wither's Operation Safety Net and wanted to do their part locally. After a few months of training and consultation with Dr. Withers, they started making rounds in Morgantown.

The students linked up with formerly homeless individuals in the community as well as the local mental health agency to help establish their credibility on the streets.

From the start, the program was designed purely by students, Dr. Deci said. It continues to be run and managed by students, who handle everything from inventory and volunteers to policy development. They make street rounds every other week.

"You're not there to change people, but to validate them as human beings worthy of quality care," Dr. Deci said.

The role of all the volunteers in the program is to provide care, but also respect, he said.

Dr. Deci counseled patience for physicians who want to reach out to unsheltered homeless individuals. These new patients may be skeptical of your involvement at first, but if you show up consistently they will come around, he said.

Starting small is also important. Although Dr. Deci and his students would like to be making street rounds every night, they have settled on going out once every 2 weeks so they can provide a consistent presence.

There are challenges to providing care on the street, from record keeping to obtaining malpractice coverage, but Dr. Withers said he has found that many of his volunteers like to do it simply because it's rewarding. It's a great service for the homeless people living on the street, he said, but it's an even greater service for the physicians, nurses, and others who volunteer their time.

For more information about street medicine programs or the International Street Medicine Symposium, visit www.streetmedicine.org.

BY MARY ELLEN SCHNEIDER

New York Bureau

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Author:Schneider, Mary Ellen
Publication:Internal Medicine News
Geographic Code:1USA
Date:Sep 15, 2007
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